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Inspection on 25/01/06 for Queen Elizabeth House

Also see our care home review for Queen Elizabeth House for more information

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The management team and staff work hard to ensure the needs of all service users who live at the home. During a period of considerable change regarding the running and operation of the home, service users and staff have been kept well informed and reassured. The home has a wide and varied selection of activities that take place on a daily basis. Service users spoke of receiving quality care from a dedicated staff team within a homely, relaxed and friendly atmosphere. The home caters for a variety of cultures and ensures individual needs are fully met.

What has improved since the last inspection?

Since the last inspection the home has begun an extensive programme of redecoration and furnishing in order to provide service users with an attractive and welcoming place to live. The communal dining room has been extended and now provides a light and airy environment in which to eat. Staff assist and encourage service users to maintain contact with family and friends.

What the care home could do better:

Further development to the home`s medication policies and procedures is required to ensure the sound management of service users` medication. A detailed matrix of staff training needs should be compiled and regularly reviewed. To ensure the safety of service users, window restrictors should be placed on all first floor windows.

CARE HOMES FOR OLDER PEOPLE Queen Elizabeth House Queen Elizabeth Road Eastmoor Wakefield WF1 4AA Lead Inspector Elizabeth Hendry Unannounced Inspection 25th January 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address Queen Elizabeth Road Eastmoor Wakefield WF1 4AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 302395 01924 307792 Wakefield MDC Mr Paul Smith Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Respite care for 2 service users The work required to meet the recommendations of the latest Fire Officer’s report is completed by 31 March 2004 or within an earlier timescale if this is stipulated by the Fire Service The care staffing hours are calculated by the provider using the Residential Forum staffing model and the number of full time equivalent staff appointed is in accordance with this calculation or otherwise as agreed in writing with the NCSC 4th August 2005 Date of last inspection Brief Description of the Service: Queen Elizabeth House is a purpose built care home for older people operated by the Social Care Dept of Wakefield Metropolitan District Council. The home has 27 beds plus communal areas including dining room, smokers’ lounge and non-smokers’ lounge. At the rear of the home leading from the non-smoking lounge is an additional room, which leads out onto a paved patio area and into the rear garden. The rear garden is mainly grassed with shrubs and borders as well as a greenhouse. To the front of the home is a car parking area and grassed areas. The home has hairdressing and laundry facilities. The home does not provide nursing care but is supported by local Health Centres and the GPs and Primary Care Teams visit as required. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second annual unannounced inspection which took place over the course of a few hours. Time was spent talking with service users and staff. Care plans, medication and policies and procedures were also inspected. The inspector would like to thank the management, staff and residents of the home for their hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home has begun an extensive programme of redecoration and furnishing in order to provide service users with an attractive and welcoming place to live. The communal dining room has been extended and now provides a light and airy environment in which to eat. Staff assist and encourage service users to maintain contact with family and friends. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9 and 10 Service users’ healthcare needs are met. The systems for medication administration are poor; arrangements currently in place do not ensure service users; medication needs are met. Service users are treated with respect and dignity. EVIDENCE: Staff closely monitor all residents to ensure their healthcare needs are met. Records viewed confirmed that any problems identified are quickly addressed. Medication administration records were checked and referenced against medication held within the home. Significant discrepancies were identified and raised with the manager during the inspection. The Registered Manager confirmed that the most senior member of staff on shift is responsible for the administration of medication. Staff training files identified a need for staff to undertake a more in depth medication training course in addition to the in-house training provided on commencement of their duties. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 10 The Registered Manager confirmed that service users receive regular medication reviews with their chosen GP. Controlled drugs held within the home were appropriately stored and recorded. All drugs received into the care home are checked and recorded within the medication administration records. Throughout the course of the inspection, staff were observed interacting well with all service users and treating them with respect and dignity. Daily records and service user meeting minutes confirmed that service users were involved in making decisions regarding their daily routine. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Service users are fully supported to participate in activities and develop personal interests. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets all of the service users’ tastes and choices. EVIDENCE: The Registered Manager confirmed that there is a wide range of activities available within the home; these include music, bingo, raffles, arts and crafts, creative writing, reminiscence and light armchair activities. One service user spoken to said that they enjoy the summer months when the home organises day trips. The home accesses two peripatetic activity organisers who visit twice a week to provide a varied selection of activities. Service users spoke of enjoying day trips to local attractions and the seaside during the summer months. The Registered Manager spoke of holding regular service user meetings to enable residents to express interest in particular activities or excursions. Minutes viewed and service users spoken to confirmed this. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 12 Staff files viewed identified successful completion of training in organising and undertaking activities. The home has a four week menu with daily choices being offered to service users. Residents spoken with were very complimentary regarding the standard of meals and said that hot and cold drinks and snacks are available upon request. Menus viewed showed careful planning and indicated choices available for each meal. Service user meetings are used as an opportunity for residents to identify what meals they would like putting on the menu. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Arrangements for the protection of service users are not satisfactory placing them at possible risk. EVIDENCE: Staff members spoken with were unclear as to the correct procedure for reporting possible instances of abuse. Staff training records viewed identified that a large proportion of staff had not undertaken any adult protection training. The home had no outstanding adult protection alerts at the time of the inspection. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the environment is good, providing service users with an attractive and homely place to live. Infection control measures are in place, which promotes the well being and health of service users and staff. EVIDENCE: A tour of the home was undertaken, a good standard of decoration was found throughout the home. A comprehensive programme of redecoration and refurbishment is currently underway to further enhance the environment. Service users spoken to said that they liked the changes that had taken place and that it has caused no inconvenience or disruption to them. Service users were seen to have personalised their bedrooms. The home was found to be clean throughout with no offensive odours present. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 15 Staff were observed demonstrating good practice with regards to infection control, despite many not having attended any training. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Service users do not always receive care from appropriately trained staff. EVIDENCE: Staff training files viewed identified a lack of training in a number of areas, these included the safe administration of medication, manual handling and adult protection. A copy of the home’s training matrix confirmed that training was required for a number of staff in many mandatory courses. A high proportion of staff have attended and successfully completed first aid training. The home places a strong emphasis on staff achieving NVQ level 2 or above, staff files and records viewed confirmed this. The Registered Manager spoke of staff training needs being identified during the supervision and appraisal process. Staff members spoken with had a sound understanding as to the individual needs of each service user. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Service users’ financial interests are protected through the home’s procedures. EVIDENCE: The Registered Manager explained that some service users prefer the home to manage their finances. Of those finances checked, three tallied with the records and monies held. The final monies checked was found to hold more funds than recorded on the sheet. The Registered Manager investigated this and the records have been amended in favour of the service user. All monies held on behalf of the service users are kept locked securely, with only the most senior members of staff on duty having access. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X x Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? yes Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 20 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Timescale for action The registered person shall make 25/01/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall make 01/03/06 arrangements, by training staff or by other measures to prevent service users being harmed or placed at risk of harm or abuse. The registered person must 01/04/06 ensure that staff receives regular updated training to ensure the safety of residents and safe working practices in the home. Requirement 2. OP18 13 (6) 3. OP30 18(1a) 18(1c) (i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19 Good Practice Recommendations First floor windows to be fitted with window restrictors. Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Elizabeth House DS0000034425.V281984.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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